COPD Evaluation Medical Note Template
The COPD evaluation MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, pulmonologists, and other health care providers that evaluate patients with known or suspected COPD in ambulatory or hospital settings. This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with COPD.
This MedicalTemplate contains detailed checklists for the severity of COPD symptoms, current and planned COPD therapy, and other features helpful for a comprehensive COPD treatment plan.
- E&M Documentation Template
- Digital Health Record
- Digital Signature Option
- Reminders
- Labs
- Therapeutic options
- Severity of illness
| Template updated
2/8/08 | Template Features |
Impact of COPD on the Healthcare system
The National Center for Health Statistics reports COPD to be the 4th leading cause of death in the Unites States, causing 124,000 deaths per year. Over 24 million Americans have COPD, and women are more likely than men to die from COPD. The major risk factor for developing and dying from COPD is tobacco smoking. COPD is responsible for over 1 million hospital admissions and $37 billion dollars in healthcare costs each year. Due to the large numbers of Americans with COPD and the heath care costs associated with the treatment of COPD, this chronic lung disease is a focus of many quality improvement initiatives and pay for performance programs.
E & M Documentation Template
The COPD evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a new patient evaluation, consult, or follow up note.
When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.
History Click here to learn about History Documentation
- Chief complaint
- History of present illness
- Past medical and surgical history
- Social history
- Risk
factors for disease (occupational exposures, smoking, and
others)
- Family history
- Review of systems
- Yes/No checkboxes for clear and complete documentation
Examination Click here to learn about Physical Exam Documentation
- When
completed, represents a comprehensive (highest) level physical exam as
defined in 1997 Guidelines.
- General Multisystem Exam
- Checkboxes
for pertinent negatives and common positive findings
Medical Decision Making Click here to learn about MDM Documentation
- Full
page
for adequate space with complex patients
- Easy Documentation with checkboxes
- Review of labs, tests, imaging, old records
- Coordination of care
- Common diagnostic and therapeutic options
- Assessment and plan
Medical Documentation References and Resources
- 1997
Documentation Guidelines for Evaluation and Management
Services
- 1995
Documentation Guidelines for Evaluation and Management
Services
- HGSA
Documentation worksheet
- Trailblazer
Health documentation worksheet
(for DE,
MD, TX, VA, or the DC)
- Medicare
Audit and/or Coding Worksheet
Digital Health Record
The COPD follow up evaluation MedicalTemplate functions like all other PDF files, but they have editable text fields and working checkboxes. This allows information to be typed in or pasted from other applications to fill out the template.Filled MedicalTemplates can be printed and saved to a computer, USB drive, CD, DVD, or other storage device to create a digital health record for your patients.
To learn more about how MedicalTemplates can be used as a digital health record, click here.
Digital Signature Enabled
To learn more about Adobe PDF digital signatures, click here.
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Pay for Performance
The COPD patient encounter template was designed to include Clinical Performance Measures for COPD developed by the Physician Consortium for Performance Improvement.
The Clinical Performance Measures for
COPD can be downloaded from
here.
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MedicalTemplates are in the Adobe PDF format, which requires the free Adobe Reader. With Adobe Reader, these templates can be printed as many times as needed on paper meeting your specifications or the specifications of any clinic, hospital, or other health care facility.
